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I understand that I am financially responsible for any charges not covered by my benefits. It is my responsibility to notify office of any changes to my benefits. In some cases, exact insurance benefits cannot be determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill if the submitted claims or any part of them are denied for payment. I understand that by signing this form I am accepting financial responsibility as explained above for all payment for products and services received. I authorize office to submit insurance claims on my behalf and to release information necessary to my insurance company for the processing of those claims. I assign all dental benefits for services rendered and authorize and direct my insurance carrier(s) to issue payment directly to office. I certify that the information I have provided is accurate to the best of my knowledge.

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05 July 2022 at 07:09 PM by IP 3.236.221.156

Dentistry at Millennium Park

Stephen J. Gordon, DDS

NOTICE OF PRIVACY PRACTICES and IMPORTANT INFORMATION

This notice describes how health information about you may be used and disclosed and how you can get access to this information and additional important financial information. Please review it carefully.

Thank you for choosing Dentistry at Millennium Park. The privacy of your health information is important to us.

OUR LEGAL DUTY:

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes affect: 01/01/2013 and replaces the NOTICE dated 10/07/2002.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment and healthcare operations. For example:

TREATMENT: We may use or disclose your health information to a physician or other healthcare provider providing treatment for you.

PAYMENT: We may use and disclose your health information to obtain payment for services we provide to you.

HEALTHCARE OPERATIONS: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include, but are not limited to: quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, response to posted reviews, and credentialing activities.

YOUR AUTHORIZATION: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

TO YOUR FAMILY AND FRIENDS: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

RESEARCH: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the proposal and established protocols to ensure the privacy of your health information.

BUSINESS ASSOCIATES: We may disclose your health information to our business associates so that they can perform their job that we ask them to do. We require these associates to appropriately safeguard your information.

FOOD AND DRUG ADMINISTRATION (FDA): We may disclose to the FDA any health information relative to adverse events with respect to products and product defects in order to enable recalls, repairs or replacement.

PUBLIC HEALTH: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.

WORKERS COMPENSATION: We may disclose health information to the extent authorized by and to the extent required to comply with the law.

INSURANCE: We will disclose health information necessary, as requested by you Insurance Carrier (Dental and/or Medical) as deemed necessary for the processing of your claim.

APPOINTMENT REMINDERS AND OTHER CONTACT: We may use or disclose your health information to contact you to provide appointment reminders or information about treatment options or alternatives or other health-related benefits and services that may be of interest to you. We routinely use, but are not limited to: telephone, facsimile (fax), mail, email and/or telephone text messages for such contacts. If you do not wish to receive these types of communication, please advise us in writing.

PERSONS INVOLVED IN CARE: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, radiographs (x-rays), dental appliances or other similar forms of health information.

MARKETING HEALTH-RELATED SERVICES: We may use your health information for marketing communications or educational purposes, without your additional authorization. These may include photographic images, video images, radiographic (x-ray) images which typically would not be identifiable as you.

REQUIRED BY LAW: We may use or disclose your health information when we are required to do so by law.

ABUSE OR NEGLECT: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

NATIONAL SECURITY AND LAW ENFORCEMENT: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials, health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement officials, having lawful custody, the health information of inmate or patient under certain circumstances.

PATIENT RIGHTS:

ACCESS TO YOUR HEALTH INFORMATION: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will try to use the format you request unless we cannot practicably do so.

NOTE: You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses that we incur, such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $2.00 per page for standard paper photo copies, $5.00 per page for copies using photographic paper and $15.00 per hour for staff time to locate and copy your health information and postage, if you want the copies mailed to you.

If you request an alternative format we will charge a cost-based fee for providing your health information in that format. (including, but not limited to CD rom disk, DVD disk copies or Flash Drive). If you prefer, we will prepare a summary or an explanation of your health information, for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.

DISCLOSURE ACCOUNTING: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years. If you request this accounting more than once in a 12-month period, we will charge you a reasonable, cost-based fee for responding to those additional requests.

RESTRICTION: You have the right to request us to place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

ALTERNATIVE COMMUNICATION: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

ADMENDMENT: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended). We may deny your request under certain circumstances.

ELECTRONIC NOTICE: If you receive this Notice on our Website or by electronic mail (email), you may print it out. You are entitled to receive this Notice in written form, but you must ask for it in writing.

OFFICE POLICY:

We like having knowledgeable patients and strive to educate patients regarding their current dental condition. We invite you to discuss with us any questions regarding our services or your dental needs.
The best dental health services are based on a friendly, mutual understanding between the provider Dentist and Hygienist and the Patient
Office policy requires payment, in full, for all services rendered at the time of the visit. We accept all major credit cards, cash, checks, and offer extended payments through Care Credit or LendingUSA.
If your account is not paid within 60 days of the date of service, you will be responsible for legal fees, collection agency fees, interest charges, and any other expenses incurred in collecting your account - We report to the Credit Bureaus.
If you do not come to your appointment and do not cancel within 48 hours, you will be charged a missed appointment fee.
We reserve the right to correct any and all billing errors or discrepancies without any time limit.
We are not responsible for lost or stolen items.
Dental Insurance is a contract between the Patient and the Insurance Company. We fill out and submit dental claims as a courtesy to our patient but we do NOT guarantee that the Insurance Company will make ANY payment towards the procedures performed. Ultimately the cost is Your Responsibility.
The Insurance Company may request further information which we will attempt to fulfill, but any outcome of the Insurance Claim is the sole responsibility of the patient.
If you require duplication of Radiographs (x-rays) or other information to be sent to an insurance carrier or other dental office, you will be charged the allowable State of Illinois Duplication Fee.
Discounts and Professional Courtesy’s are a bonus that is earned. If the patient does not live up to their payment, the discount will be forfeited and the patient will be charged the routine fee for all dental work.
A billing charge is placed on all accounts over 30 days, we appreciate the prompt payment of your bill.
You understand that Dentistry is NOT an exact science and therefore reputable practitioners cannot guarantee results. You also acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment. There is no guarantee that the result of any dental treatment will be successful.
You authorize us to perform any necessary services needed during diagnosis and treatment.
Antibiotic pre-medication and usage may reduce the effectiveness of Birth Control Pills.
For patients with Dental Insurance (which requires Claim Forms): you are authorizing the provider to release any information required to process insurance claims and to assign benefits (payment) to our Dental Office.
Dental Devices (including but not limited to: Surgical Stents, Crowns, Laminate Veneers, Bridges, Guards) are custom fabricated for the patient and therefore cannot be used by anyone else. Once they are started, there are no refunds.

QUESTIONS AND COMPLAINTS:

If you want more information about our privacy practices or you have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may contact us using the contact information at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services . 200 Independence Avenue. SW. Room 509F. HHH Building, Washington. DC 20201

Contact Officer: Stephen J. Gordon, DDS Telephone: 312-750-9000 Fax: 312-750-9100 Email: sgordondds@gmail.com

Address: Dentistry at Millennium Park, 8 South Michigan Avenue, Suite 1800, Chicago, IL 60603

Written Financial Policy: Thank you for choosing Dentistry at Millennium Park.

Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.

Payment Options: Cash, Visa, Mastercard, American Express or Discover Card, Commercial Financing (Care Credit)

Please note:
Dentistry at Millennium Park requires payment prior to or at the time of treatment, unless other arrangements have been made. A Billing Charge will incur on accounts over 30 days. For patients with dental insurance we are happy to work with your carrier to maximize your benefit and provide the documentation needed to receive reimbursement (if available) for your treatment. A fee is charged for patients who miss or cancel more than 1 time in a calendar year without 48-hour notice. Dentistry at Millennium Park charges a fee for returned checks. We reserve the right to correct any and all billing errors.

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

SECTION B: TO THE PATIENT – PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY:

PURPOSE OF CONSENT: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operation.

NOTICE OF PRIVACE PRACTICES: You have the right to read our Notice of Privacy Practices and Important Information before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices and Important Information. If we change our privacy practices, we will issue a revised Notice, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of out Notice of Privacy Practices and Important Information, including any revisions of our Notice at any time by contacting:

Contact Person: Stephen J. Gordon, DDS

Phone: 312-750-9000; Fax: 312-750-9100; Email: SGordonDDS@DatMP.com

Address: Dentistry at Millennium Park, 8 South Michigan Avenue, Suite 1800, Chicago, IL 60603

RIGHT TO REVOKE: You will have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will NOT affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you, if you revoke this Consent.

Type name:

Relationship To the Patient:

I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices and Important Information. I understand that by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.

Signature:

YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT

If you have any questions, please do not hesitate to ask.

We are here to help you get the dentistry you want and need.

05 July 2022 at 07:09 PM by IP 3.236.221.156